Food Coma: Hyperammonemic Encephalopathy From Refeeding Syndrome.

Area of Science:

• Oncology
• Neurology
• Nephrology

Background:

• Extrahepatic hyperammonemic encephalopathy (HAE) is an emerging clinical concern.
• Refeeding syndrome involves significant fluid and electrolyte shifts upon nutritional reintroduction.

Observation:

• A 67-year-old man with maxillary sinus squamous cell carcinoma on nivolumab developed coma after starting enteral feeding.
• Initial findings included severe hypophosphatemia (<1 mg/dL) and elevated ammonia (226 µmol/L).

Findings:

• Hypophosphatemia correction did not resolve coma.
• Ammonia levels fluctuated with enteral feeding, worsening upon resumption.
• Continuous renal replacement therapy was considered but not initiated.

Implications:

• This case suggests HAE can be precipitated by refeeding in malnourished cancer patients.
• Impaired urea cycle and extrahepatic ammonia detoxification may play a role.
• Nivolumab's potential contribution to HAE warrants further investigation.